CMS Releases FAQ on Autism Guidance

The Centers for Medicare and Medicaid Services (CMS) has published an FAQ discussing its recent Informational Bulletin on approaches available under Medicaid for providing services to individuals with Autism Spectrum Disorder (ASD). In the Information Bulletin, CMS discussed the various authorities under which services to address ASD could be reimbursed including section 1905(a) of the Social Security Act (the Act). The bulletin also reviewed state obligations under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, where states must cover all medically necessary services for children, including services to address ASD.

In the first question, the FAQ emphasizes that CMS has not mandated Applied Behavior Analysis (ABA) services for children under 21 with Autism Spectrum Disorder (ASD). The document says that “Applied Behavior Analysis (ABA) is one treatment modality for ASD,” and adds that “ CMS is not endorsing or requiring any particular treatment modality.” The FAQ repeats that “states are expected to adhere to long-standing EPSDT obligations for individuals from birth to age 21, including providing medically necessary services available for the treatment of ASD.”

In the FAQ, CMS also states that “There is no specific time frame for CMS review of state practices in this area.” While pointing out that the information bulletin “discusses the obligations under the Medicaid statute and regulations that are already in effect,” CMS recognizes that “states may not have focused on the application of these requirements in this area” and that “a state may need time to review its current program policies to determine if changes are needed to existing state regulations and/or policy to ensure compliance.” CMS also suggests that states may “confer with the stakeholder community for public input on the benefit design of autism services for children.” CMS believes states “should complete this work expeditiously and should not delay or deny provision of medically necessary services,” and offers “technical assistance to states to ensure the availability of services that children may need.”

The FAQ also indicates that a state that has a section 1915(c) home and community-based services waiver that is limited to EPSDT-age individuals but includes services related to Autism Spectrum Disorder (ASD) that are now available through the state plan should provide such services through the Medicaid state plan for the EPSDT-eligible individuals, rather than the 1915(c) waiver. CMS will “work with states to ensure that such services are able to be made available under the state plan” and “to remove the service from the 1915(c) home and community-based services waiver at the next amendment or renewal, whichever comes first. If a state has a 1915(c) waiver that includes individuals in the EPSDT age group and also individuals beyond their 21st birthday, the ASD-related services for EPSDT eligible individuals (under age 21) must be provided under the Medicaid state plan and not under the 1915(c) waiver. When the state submits the home and community-based services waiver for renewal or amendment, the state should include a restriction under the ‘limits’ section for that specific service indicating that EPSDT-aged individuals are excluded as the services are fully covered in the state plan. ASD-related services for individuals over age 21 may continue to be provided under the 1915(c) waiver.